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Please print or type.(Form designed for use an elite 12-pittewriter.) • Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS j,!,G&njmtorIDNUnrber 2.Page 1 of <br /> I 1 3.Emuhg0* 4.ManhR-Tracking Number <br /> WASTE MANIFEST <br /> 000555493 FLE <br /> 5.Generators Name and Mailing Address <br /> Generators She"i(a onmerent than mailing address) <br /> Generator's Phonek 0�' <br /> WAks f Faf)i�.. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> A <br /> �:d1 0 1 1,A I 1 11 AA Ll �M QMT'isr' <br /> W)F=WJAINI CA 953f7 VOQt itch.;-P,T93 <br /> Facility's Phone <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HIM and Packing Group litany)) No Type Quantity Wt Noi 13.Waste Codes <br /> 1. 1A OH! I,lei 11 <br /> it IS AA l'011 V WA it-iii <br /> 3 <br /> 4 <br /> 14.Special Handling instructions and Additional Intonation <br /> 611-41L)VE4 <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described soon by the proper shipping name,and are classified,packaged, <br /> marked andlabeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.If export shipment and I am the Primary <br /> Exporter.I cartily that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I cerfify that the waste minimization statement identified in 40 CFR 21(if I am a large quami geperator)or(b)(if I am a small quanlity generator)is true. <br /> Generatoes/Offeroes Printed/Typed Name Pignatum Morith Dkay, Year <br /> 16.International shipments ❑Import to U.S, EIE-po'n from U.S. Part of entryqexit: <br /> Transporter signature for exports only): Date leaving U.S. <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 PrintedifTyped Name I <br /> signature <br /> 0 <br /> M Transporter 2 Printedfryped Name ignaty <br /> Moom Day Year <br /> I18.Discrepancy <br /> 18a.Discrepancy Indication Spam El Quantity EITYP- ❑Residue El Partial❑ Rejection Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems), <br /> 1 2. 3. <br /> Notice:New federal form. State of <br /> California requires generator to photocopy <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item file and mail to DTSC within 30 days: <br /> PrinfintrTyped Name I Signature P.C.Box 400,Sacramento,CA 95812-0400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />